Who knows about insurance? Am I getting shafted?

Aetna needs medical records stating that I've been "severely overweight" for at least five years.  Severely overweight is defined as BMI of 35 with any co-morbidity.  Currently I am BMI of 38 and got a January '07 diagnosis of sleep apnea.  If I use a low height of 5' 5" rather than 5' 6", I can be as low as 210 to have a BMI that meets the minimum.  My only problem is I don't think I've ever been "severely overweight" using the previously stated definition for five continuous years. Here's what I mean, say I was 210 to 220 for a year or two in around 1996.  I then lost 50 or so lbs to get down to 170.  Then I slowly regained weight til I was between 210 and 220 for again a year or two in 2001.  Dieted and exercised down again to 170 lbs. Fast forward to now.  I'm 230 now, but have only been over 210 since late 2005 or early 2006.  I also only have a two month history of sleep apnea.   So although I've been overweight enough to have a BMI of at least 35 for more than 5 years they are not 5 successive years, not to mention that they were not in conjunction with a medically diagnosed history of sleep apnea during the same time. Here's the question....Am I screwed?  Does anyone have any knowledge on this?  Thanks. Sonny

From your description it sounds like you should be able to put together a collection of medical records over the past five years that show you to be sufficiently overweight if you have gone to the doctor regularly.  I would see if you could work with your doctor's office to put together such a collection of records and submit that to Aetna.  Then the ball is in their court.

Sonny

i  am going threw a very similar thing.  i need 5 yr history too.  but in the last 5 years my bmi has been as high as 42 and low as 36 and back up to a 42.  i submitted all my paperwork and im waiting for a response. i will let you know what happens.  im on the edge of my chair.  every time the phone rings i run to answer it and keep checking my messages when im not home.  i think im starting to loose it...i couldnt sleep over this insurance stuff last night.

 

adam

Sonny, Is self pay an option for you?  You might fall into the "grey area" that some folks manage to get approved and some don't. I can only speak to my own situation but in my case, I had no co-morbidities and my BMI was just barely 40 so I knew that insurance was probably going to be a long and tough road. At the same time  I knew ithat  I was headed directly for much higher BMI's down the road courtesy of my lack of self control and I knew I didn't want to spend another 5-10 years being 100 lbs overweght and not enjoying my life.  I felt that I would undoubtedly be discouraged by the insurance company making me jump through a lot of hoops proving I met their predefined conditions..  So, I bit the bullet and went the self pay route. I had a VSG last October and the total out of pocket expenses were < 20k and were deductable on my taxes! I realize that I am lucky to be able to go this route and that not everyone has that option but in all honesty, it was worth it a dozen times over for me.  I try to think about it this way: the cost is less than a cheap car and you'll be driving your body around for the rest of your life while a car may last a few years.  Really, I did think of it this way.  Maybe it wouild make enduring the insurance approval  process easier just knowing that you have the self pay opton available as a last resort? Good luck! JP

Aetna is notoriously resistant to approving WLS. My advice to you is to present exactly what you did here - you can demonstrate repeated failures of dieting, with a return to "severely overweight" status each time, and new development of co-morbidity. I would venture to guess that Aetna, being the difficult SOBs that they are, will deny you the first time, then approve you on appeal, because you clearly qualify. Prepare to fight, document thoroughly, and expect to take about another year - Aetna WILL require you to be on a doctor-supervised diet for 6 months AFTER they approve you.

     Guess I am lucky Aetna paid 100% of my WLS. I did have tho a high BMI and had to do the 6 month supervised weight loss program and had to see my surgeon three months in a row before final approval. Before I had my WLS I had to have a bird's nest filter placed and Aetna also paid 100% of that totaling a bill of almost $74.000.00. Aetna has been very good to me over the years they have paid out $ 518,345.46 total on all of my medical bills with me not having to pay out dollar one of my own pocket. Keep after them and I think in the long run they will pay for your WLS. Good Luck.